Cognitive behavioural therapy methods
The following section illustrates how common cognitive and behaviour therapy methods can be applied within a headache programme.
The diagram “Headaches after Mild Brain Trauma” serves as template for matching psychosocial headache symptoms with suitable therapy methods.
Figure 2.5 Headaches after mild brain trauma.
Headache therapy would be easier if pain processing could be separated from psychological processing. The headache itself could be more directly managed if one could regulate heightened distress, anxious worrying and behavioural preoccupation separately from the pain or its consequences. However, these processes are neurophysiologically fused together. For instance, the anticipation, the experience of adversity and headache worry, as well as mental preparation for expected pain altogether, drive the stress or allostatic processes, which prolong the condition.
Pain signals a potential threat to survival. Overriding the Central Sensitisation and encouraging relearning, de-conditioning and central reorganisation takes time, practice and, as already mentioned, dedication. Therapy aims and methods need to be clear and structured in order to modulate ingrained headache pathways.
In parallel to the management of secondary stress, the person with headaches learns to acknowledge and re-evaluate pain sensations, which can open up opportunities for positive coping. New pathways develop only as a result of well-practised adaptive strategies and actions, which ultimately should be more important than the pain. These opportunities for a healthier choice of behaviour need to be encoded in new neurophysiologically mechanisms.
In the formulation process, patients separate the multi-layered meanings of the headache from its physical parameters. The assumption is that patients who understand the headache as a redundant physical sensation can learn to habituate to it. Patients can then acknowledge the pain as a neutral sensory perception and disconnect it from their fears and avoidance behaviours.
Patients may have a preferred coping style. They may be avoiders or “pushers” with an unrelenting achievement-focused or endurance style. Theoretically, patients with an avoidance style would most benefit from exposure techniques and patients with an endurance style from a paced and graded activity approach. Nevertheless, in applied therapy and day-to-day life, such coping styles can rarely be so neatly separated. Most behavioural methods used in the headache programme contain a combination of techniques.